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PURPOSE OF REVIEW: Recent advances in the field of interventional pain management (IPM) involve minimally invasive procedures such as percutaneous lumbar decompression, interspinous spacer placement, interspinous-interlaminar fusion and sacroiliac joint fusion. These developments have received pushback from surgical professional societies, who state spinal instrumentation and arthrodesis should only be performed by spine surgeons. The purpose of this review is to evaluate the validity of this claim. A literature search was conducted on Google Scholar and PubMed databases. Articles were included which examined IPM in the following contexts: credentialing and procedural privileging guidelines, fellowship training and education, and procedural outcomes compared to those of surgical specialties. Our primary research question is: "Should interventionalists be performing decompression and fusion procedures?". FINDINGS: Advanced percutaneous spine procedures are not universally incorporated into pain fellowship curriculums. Trainees attempt to compensate for these deficiencies through industry-led training, which has been criticized for lacking central regulation. There is also a paucity of studies comparing procedural outcomes between surgeons and interventionalists for complex spine procedures, including decompression and fusion. Pain fellowship curriculums have not kept pace with some of procedural advancements within the field. Interventionalists are also not trained to manage potential complications of spinal instrumentation and arthrodesis, which has been recognized as an essential requirement for procedural privileging. Decompression and fusion may therefore be outside the scope of an interventionalist's practice.
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Descompressão Cirúrgica , Manejo da Dor , Humanos , Descompressão Cirúrgica/métodos , Dor/cirurgia , Vértebras Lombares/cirurgia , Procedimentos NeurocirúrgicosRESUMO
PURPOSE OF REVIEW: With this manuscript the authors sought to write a succinct review of the origins, as well as the latest advancements in endoscopic spine surgery to serve as a reference frame for physicians looking to learn this approach. RECENT FINDINGS: At its infancy, the indications for posterolateral and transforaminal endoscopic decompression remained narrow, which prevented the procedure from gaining rapid traction during those days. However, more recently the tides have turned and an increasing number of surgeons are starting to adopt this technique given all its advantages. With the advent of higher quality camera systems and instruments, indications to use a minimally invasive option have gotten significantly broader. The most basic indication for the use of this technology is a soft disc herniation causing compromise of a neural structure that has failed to be managed successfully with non-surgical therapies. The use of endoscopic techniques provides significant advantages to patient outcomes and patient recovery. Endoscopic procedures should not be used as a blanket approach to nerve root decompression, as they certainly have limitations. Most contraindications to this procedure are relative and serve mostly as points to consider when selecting the methods to address neural compression. As these techniques become more widely accepted, we expect its reach and indications to continue to broaden and diversify. The full integration of navigation technologies will likely leapfrog this procedure into the mainstream use.
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Deslocamento do Disco Intervertebral , Radiculopatia , Descompressão Cirúrgica/métodos , Humanos , Deslocamento do Disco Intervertebral/complicações , Deslocamento do Disco Intervertebral/cirurgia , Vértebras Lombares/cirurgia , Procedimentos Cirúrgicos Minimamente Invasivos/métodos , Radiculopatia/etiologia , Radiculopatia/cirurgia , Resultado do TratamentoRESUMO
OBJECTIVE: The accuracy of percutaneous pedicle screw placement has increased with the advent of robotic and surgical navigation technologies. However, the effect of robotic intraoperative screw size and trajectory templating remains unclear. The purpose of this study was to compare pedicle screw sizes and accuracy of placement using robotic navigation (RN) versus skin-based intraoperative navigation (ION) alone in minimally invasive lumbar fusion procedures. METHODS: A retrospective cohort study was conducted using a single-institution registry of spine procedures performed over a 4-year period. Patients who underwent 1- or 2-level primary or revision minimally invasive surgery (MIS)-transforaminal lumbar interbody fusion (TLIF) with pedicle screw placement, via either robotic assistance or surgical navigation alone, were included. Demographic, surgical, and radiographic data were collected. Pedicle screw type, quantity, length, diameter, and the presence of endplate breach or facet joint violation were assessed. Statistical analysis using the Student t-test and chi-square test was performed to evaluate the differences in pedicle screw sizes and the accuracy of placement between both groups. RESULTS: Overall, 222 patients were included, of whom 92 underwent RN and 130 underwent ION MIS-TLIF. A total of 403 and 534 pedicle screws were placed with RN and ION, respectively. The mean screw diameters were 7.25 ± 0.81 mm and 6.72 ± 0.49 mm (p < 0.001) for the RN and ION groups, respectively. The mean screw length was 48.4 ± 4.48 mm in the RN group and 45.6 ± 3.46 mm in the ION group (p < 0.001). The rates of "ideal" pedicle screws in the RN and ION groups were comparable at 88.5% and 88.4% (p = 0.969), respectively. The overall screw placement was also similar. The RN cohort had 63.7% screws rated as good and 31.4% as acceptable, while 66.1% of ION-placed screws had good placement and 28.7% had acceptable placement (p = 0.661 and p = 0.595, respectively). There was a significant reduction in high-grade breaches in the RN group (0%, n = 0) compared with the ION group (1.2%, n = 17, p = 0.05). CONCLUSIONS: The results of this study suggest that robotic assistance allows for placement of screws with greater screw diameter and length compared with surgical navigation alone, although with similarly high accuracy. These findings have implied that robotic platforms may allow for safe placement of the "optimal screw," maximizing construct stability and, thus, the ability to obtain a successful fusion.
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Parafusos Pediculares , Robótica , Fusão Vertebral , Humanos , Vértebras Lombares/diagnóstico por imagem , Vértebras Lombares/cirurgia , Procedimentos Cirúrgicos Minimamente Invasivos/métodos , Estudos Retrospectivos , Fusão Vertebral/métodosRESUMO
Objective: To assess the effect depression has on outcomes after cervical epidural steroid injections (CESIs). Design: Retrospective review of a prospectively collected database. Setting: Single institution tertiary care center. Subjects: Fifty-seven patients with cervical spondylosis and cervical radicular pain who were deemed appropriate surgical candidates but elected to undergo CESI first were included. Methods: Twenty-one of 57 (37%) patients with depression (defined as Zung Depression Scale >33) were included. Patient-reported outcomes including Neck Disability Index (NDI), numeric rating scale (NRS) for arm pain (AP), NRS for neck pain (NP), and EuroQol-5D (EQ-5D) were collected at baseline and three-month follow-up. Minimal clinically important differences were then calculated to provide dichotomous outcome measures of success. Results: Overall, 24 and 28 patients achieved at least 50% improvement in AP and NP, respectively. In terms of disability, 25/57 (43.9%) patients achieved >13.2-point improvement on the NDI overall. In patients with depression, 4/21 (19.0%) and 5/21 (23.8%) achieved at least 50% improvement on the NRS for AP and NP, respectively, compared with 20/36 (55.5%) and 23/36 (63.8%) in patients without depression. This difference was statistically significant for both pain measures (P < 0.002 AP, P < 0.006 NP). Statistically fewer patients, 5/21 (24%), with depression achieved ≥13.2-point improvement on the NDI compared with 20/36 (55%) nondepressed patients (P < 0.01). There was no difference in outcomes between groups on the EQ-5D. Conclusions: Patients with cervical spondylosis and comorbid depression who undergo CESI are less likely to achieve successful outcomes in both pain and function compared with nondepressed patients at three months.
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Depressão/complicações , Transtorno Depressivo/terapia , Cervicalgia/terapia , Medidas de Resultados Relatados pelo Paciente , Adulto , Idoso , Idoso de 80 Anos ou mais , Vértebras Cervicais/cirurgia , Transtorno Depressivo/complicações , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Diferença Mínima Clinicamente Importante , Cervicalgia/complicações , Medição da Dor , Satisfação do Paciente , Espondilose/complicações , Espondilose/terapia , Resultado do TratamentoRESUMO
OBJECTIVEBack pain and neck pain are two of the most common causes of work loss due to disability, which poses an economic burden on society. Due to recent changes in healthcare policies, patient-centered outcomes including return to work have been increasingly prioritized by physicians and hospitals to optimize healthcare delivery. In this study, the authors used a national spine registry to identify clinical factors associated with return to work at 3 months among patients undergoing a cervical spine surgery.METHODSThe authors queried the Quality Outcomes Database registry for information collected from April 2013 through March 2017 for preoperatively employed patients undergoing cervical spine surgery for degenerative spine disease. Covariates included demographic, clinical, and operative variables, and baseline patient-reported outcomes. Multiple imputations were used for missing values and multivariable logistic regression analysis was used to identify factors associated with higher odds of returning to work. Bootstrap resampling (200 iterations) was used to assess the validity of the model. A nomogram was constructed using the results of the multivariable model.RESULTSA total of 4689 patients were analyzed, of whom 82.2% (n = 3854) returned to work at 3 months postoperatively. Among previously employed and working patients, 89.3% (n = 3443) returned to work compared to 52.3% (n = 411) among those who were employed but not working (e.g., were on a leave) at the time of surgery (p < 0.001). On multivariable logistic regression the authors found that patients who were less likely to return to work were older (age > 56-65 years: OR 0.69, 95% CI 0.57-0.85, p < 0.001; age > 65 years: OR 0.65, 95% CI 0.43-0.97, p = 0.02); were employed but not working (OR 0.24, 95% CI 0.20-0.29, p < 0.001); were employed part time (OR 0.56, 95% CI 0.42-0.76, p < 0.001); had a heavy-intensity (OR 0.42, 95% CI 0.32-0.54, p < 0.001) or medium-intensity (OR 0.59, 95% CI 0.46-0.76, p < 0.001) occupation compared to a sedentary occupation type; had workers' compensation (OR 0.38, 95% CI 0.28-0.53, p < 0.001); had a higher Neck Disability Index score at baseline (OR 0.60, 95% CI 0.51-0.70, p = 0.017); were more likely to present with myelopathy (OR 0.52, 95% CI 0.42-0.63, p < 0.001); and had more levels fused (3-5 levels: OR 0.46, 95% CI 0.35-0.61, p < 0.001). Using the multivariable analysis, the authors then constructed a nomogram to predict return to work, which was found to have an area under the curve of 0.812 and good validity.CONCLUSIONSReturn to work is a crucial outcome that is being increasingly prioritized for employed patients undergoing spine surgery. The results from this study could help surgeons identify at-risk patients so that preoperative expectations could be discussed more comprehensively.
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Vértebras Cervicais/cirurgia , Bases de Dados Factuais/normas , Nomogramas , Indicadores de Qualidade em Assistência à Saúde/normas , Retorno ao Trabalho , Adulto , Idoso , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Cervicalgia/diagnóstico , Cervicalgia/cirurgia , Valor Preditivo dos Testes , Estudos Prospectivos , Sistema de Registros , Retorno ao Trabalho/tendências , Fatores de Tempo , Resultado do TratamentoRESUMO
PURPOSE: Non-steroidal anti-inflammatory drugs (NSAIDs) play an important role in postoperative pain management. However, their use in the setting of spine fusion surgery setting has long been a topic of controversy. In this review we examined relevant research, including in vivo, animal, and clinical human studies, with the aim of understanding the effect of NSAIDs on spinal fusion. STUDY DESIGN/SETTING: Systematic review of study designs of all types from randomized controlled trials and meta-analyses to single-institution retrospective reviews. METHODS: A search of PubMed and Embase was conducted using the keywords: "spine," "spinal fracture," NSAIDs, anti-inflammatory non-steroidal agents, bone, bone healing, fracture, fracture healing, yielding a total of 110 studies. Other 28 studies were identified by cross-referencing, resulting in total 138 studies. RESULTS: There is no level I evidence from human studies regarding the use of NSAIDs on spinal fusion rates. The overall tone of the spine literature in the early 2000s was that NSAIDs increased the rate of non-union; however, nearly all human studies published after 2005 suggest that short-term (<2 weeks) postoperative use have no such effect. The dose dependency that is seen with a 2-week postoperative course is not present when NSAIDs are only used for 48 h after surgery. CONCLUSIONS: NSAID appear to have dose-dependent and duration-dependent effects on fusion rates. The short-term use of low-dose NSAIDs around the time of spinal fusion surgery is reasonable. Spine surgeons can consider the incorporation of NSAIDs into pain control regimens for spinal fusion patients with the goal of improving pain control and reducing the costs and complications associated with opioids.
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Anti-Inflamatórios não Esteroides , Dor Pós-Operatória/tratamento farmacológico , Fusão Vertebral/métodos , Animais , Anti-Inflamatórios não Esteroides/administração & dosagem , Anti-Inflamatórios não Esteroides/uso terapêutico , Consolidação da Fratura , Humanos , Fraturas da Coluna Vertebral/cirurgia , Resultado do TratamentoRESUMO
PURPOSE: With growing older population and increasing rates of cervical spinal surgery, it is vital to understand the value of cervical surgery in this population. We set forth to determine the cost utility following anterior cervical decompression and fusion (ACDF) for degenerative disease in older patients. METHODS: Patients undergoing ACDF for degenerative diseases were enrolled into prospective longitudinal registry. Patient-reported outcomes (PROs) were recorded at baseline, 1-year, and 2-year postoperatively. Two-year medical resource utilization, missed work, and health-state values [quality-adjusted life years (QALYs)] were assessed to compute cost per QALY gained. Patients were dichotomized based on age: <65 years (younger) and ≥65 years (older) to compare the cost utility in these age groups. RESULTS: Total 218 (87%) younger patients and 33 (13%) older patients who underwent ACDF were analyzed. Both the groups demonstrated a significant improvement in PROs 2-year following surgery. The older patients had a lower mean cumulative gain in QALYs compared to younger patients at 1 year (0.141 vs. 0.28, P = 0.05) and 2 years (0.211 vs. 0.424, P = 0.04). There was no significant difference in the mean total 2-year cost between older [$21,041 (95% CI $18,466-$23,616)] and younger [$22,669 (95% CI $$21,259-$24,079)] patients (P = 0.27). Two-year cost per QALY gained in older vs. younger patients was ($99,720/QALYs gained vs. ($53,464/QALYs gained, P = 0.68). CONCLUSION: ACDF surgery provided a significant gain in health-state utility in older patients with degenerative cervical pathology, with a mean cumulative 2-year cost per QALY gained of $99,720/QALY. While older patients have a slightly higher cost utility compared to their younger counterparts, surgery in the older cohort does provide a significant improvement in pain, disability, and quality-of-life outcomes.
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Discotomia , Deslocamento do Disco Intervertebral/cirurgia , Medidas de Resultados Relatados pelo Paciente , Fusão Vertebral , Estenose Espinal/cirurgia , Espondilose/cirurgia , Fatores Etários , Idoso , Análise Custo-Benefício , Avaliação da Deficiência , Discotomia/economia , Feminino , Humanos , Deslocamento do Disco Intervertebral/economia , Estudos Longitudinais , Masculino , Estudos Prospectivos , Anos de Vida Ajustados por Qualidade de Vida , Sistema de Registros , Fusão Vertebral/economia , Estenose Espinal/economia , Espondilose/economia , Estados UnidosRESUMO
PURPOSE: To investigate the relationship between lumbar facet fluid and dynamic instability in degenerative spondylolisthesis (DS), as well as the relationship between facet fluid and patient-reported outcomes following a posterior lumbar fusion. METHODS: We analyzed consecutive patients with degenerative spondylolisthesis undergoing single level posterior lumbar fusion from December 2010 to January 2013 at a single academic institution. We investigated the relationship between fluid in the facet joint as measured on axial MRI and the presence of dynamic instability. We investigated the impact of facet fluid, Modic changes, and dynamic instability on patient-reported outcomes. RESULTS: There was a significant association between the amount of facet joint fluid and the presence of dynamic instability (p = 0.03); as facet fluid increases, the probability of dynamic instability also increases. For every 1 mm of facet fluid, there was a 41.6 % increase (95 % CI 1.8-97) in the odds of dynamic instability. A facet fluid amount less than 0.5 mm gave a 90 % probability that there was no dynamic instability. The presence of facet fluid and dynamic instability were associated with achieving minimal clinical important difference (MCID) in low back pain following lumbar fusion (p = 0.04 and 0.05, respectively). CONCLUSION: Facet joint fluid is associated with the presence of dynamic instability in DS. The presence of facet fluid and dynamic instability may predict increased likelihood of achieving MCID for improvement in back pain following posterior lumbar fusion.
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Vértebras Lombares/cirurgia , Sistema de Registros , Fusão Vertebral , Espondilolistese/cirurgia , Articulação Zigapofisária/diagnóstico por imagem , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Dor Lombar/etiologia , Vértebras Lombares/diagnóstico por imagem , Imageamento por Ressonância Magnética , Masculino , Pessoa de Meia-Idade , Diferença Mínima Clinicamente Importante , Prognóstico , Estudos Retrospectivos , Espondilolistese/complicações , Espondilolistese/diagnóstico por imagemRESUMO
OBJECT Lumbar spine surgery has been demonstrated to be efficacious for many degenerative spine conditions. However, there is wide variability in outcome after spine surgery at the individual patient level. All stakeholders in spine care will benefit from identification of the unique patient or disease subgroups that are least likely to benefit from surgery, are prone to costly complications, and have increased health care utilization. There remains a large demand for individual patient-level predictive analytics to guide decision support to optimize outcomes at the patient and population levels. METHODS One thousand eight hundred three consecutive patients undergoing spine surgery for various degenerative lumbar diagnoses were prospectively enrolled and followed for 1 year. A comprehensive patient interview and health assessment was performed at baseline and at 3 and 12 months after surgery. All predictive covariates were selected a priori. Eighty percent of the sample was randomly selected for model development, and 20% for model validation. Linear regression was performed with Bayesian model averaging to model 12-month ODI (Oswestry Disability Index). Logistic regression with Bayesian model averaging was used to model likelihood of complications, 30-day readmission, need for inpatient rehabilitation, and return to work. Goodness-of-fit was assessed via R(2) for 12-month ODI and via the c-statistic, area under the receiver operating characteristic curve (AUC), for the categorical endpoints. Discrimination (predictive performance) was assessed, using R(2) for the ODI model and the c-statistic for the categorical endpoint models. Calibration was assessed using a plot of predicted versus observed values for the ODI model and the Hosmer-Lemeshow test for the categorical endpoint models. RESULTS On average, all patient-reported outcomes (PROs) were improved after surgery (ODI baseline vs 12 month: 50.4 vs 29.5%, p < 0.001). Complications occurred in 121 patients (6.6%), 108 (5.9%) were readmitted within 30 days of surgery, 188 (10.3%) required discharge to inpatient rehabilitation, 1630 (88.9%) returned to work, and 449 (24.5%) experienced an unplanned outcome (no improvement in ODI, a complication, or readmission). There were 45 unique baseline variable inputs, derived from 39 clinical variables and 38 questionnaire items (ODI, SF-12, MSPQ, VAS-BP, VAS-LP, VAS-NP), included in each model. For prediction of 12-month ODI, R(2) was 0.51 for development and 0.47 for the validation study. For prediction of a complication, readmission, inpatient rehabilitation, and return to work, AUC values ranged 0.72-0.84 for development and 0.79-0.84 for validation study. CONCLUSIONS A novel prediction model utilizing both clinical data and patient interview inputs explained the majority of variation in outcome observed after lumbar spine surgery and reliably predicted 12-month improvement in physical disability, return to work, major complications, readmission, and need for inpatient rehabilitation for individual patients. Application of these models may allow clinicians to offer spine surgery specifically to those who are most likely to benefit and least likely to incur complications and excess costs.
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Funções Verossimilhança , Readmissão do Paciente/estatística & dados numéricos , Complicações Pós-Operatórias/fisiopatologia , Retorno ao Trabalho , Fusão Vertebral/métodos , Resultado do Tratamento , Adulto , Idoso , Estudos de Coortes , Avaliação da Deficiência , Registros Eletrônicos de Saúde/estatística & dados numéricos , Feminino , Humanos , Região Lombossacral/cirurgia , Masculino , Pessoa de Meia-Idade , Medição da Dor , Satisfação do Paciente , Valor Preditivo dos Testes , Sistema de Registros , Autorrelato , Doenças da Medula Espinal/cirurgiaRESUMO
OBJECT There is a paradigm shift toward rewarding providers for quality rather than volume. Complications appear to occur at a fairly consistent frequency in large aggregate data sets. Understanding how complications affect long-term patient-reported outcomes (PROs) following degenerative lumbar surgery is vital. The authors hypothesized that 90-day complications would adversely affect long-term PROs. METHODS Nine hundred six consecutive patients undergoing elective surgery for degenerative lumbar disease over a period of 4 years were enrolled into a prospective longitudinal registry. The following PROs were recorded at baseline and 12-month follow-up: Oswestry Disability Index (ODI) score, numeric rating scales for back and leg pain, quality of life (EQ-5D scores), general physical and mental health (SF-12 Physical Component Summary [PCS] and Mental Component Summary [MCS] scores) and responses to the North American Spine Society (NASS) satisfaction questionnaire. Previously published minimum clinically important difference (MCID) threshold were used to define meaningful improvement. Complications were divided into major (surgicalsite infection, hardware failure, new neurological deficit, pulmonary embolism, hematoma and myocardial infarction) and minor (urinary tract infection, pneumonia, and deep venous thrombosis). RESULTS Complications developed within 90 days of surgery in 13% (118) of the patients (major in 12% [108] and minor in 8% [68]). The mean improvement in ODI scores, EQ-5D scores, SF-12 PCS scores, and satisfaction at 3 months after surgery was significantly less in the patients with complications than in those who did not have major complications (ODI: 13.5 ± 21.2 vs 21.7 ± 19, < 0.0001; EQ-5D: 0.17 ± 0.25 vs 0.23 ± 0.23, p = 0.04; SF-12 PCS: 8.6 ± 13.3 vs 13.0 ± 11.9, 0.001; and satisfaction: 76% vs 90%, p = 0.002). At 12 months after surgery, the patients with major complications had higher ODI scores than those without complications (29.1 ± 17.7 vs 25.3 ± 18.3, p = 0.02). However, there was no difference in the change scores in ODI and absolute scores across all other PROs between the 2 groups. In multivariable linear regression analysis, after controlling for an array of preoperative variables, the occurrence of a major complication was not associated with worsening ODI scores 12 months after surgery. There was no difference in the percentage of patients achieving the MCID for disability (66% vs 64%), back pain (55% vs 56%), leg pain (62% vs 59%), or quality of life (19% vs 14%) or in patient satisfaction rates (82% vs 80%) between those without and with major complications. CONCLUSIONS Major complications within 90 days following lumbar spine surgery have significant impact on the short-term PROs. Patients with complications, however, do eventually achieve clinically meaningful outcomes and report satisfaction equivalent to those without major complications. This information allows a physician to counsel patients on the fact that a complication creates frustration, cost, and inconvenience; however, it does not appear to adversely affect clinically meaningful long-term outcomes and satisfaction.
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Procedimentos Cirúrgicos Eletivos/efeitos adversos , Região Lombossacral/cirurgia , Doenças Neurodegenerativas/cirurgia , Avaliação de Resultados da Assistência ao Paciente , Complicações Pós-Operatórias/fisiopatologia , Resultado do Tratamento , Adulto , Idoso , Avaliação da Deficiência , Procedimentos Cirúrgicos Eletivos/métodos , Feminino , Humanos , Estudos Longitudinais , Masculino , Pessoa de Meia-Idade , Medição da Dor , Satisfação do Paciente , Inquéritos e Questionários , Fatores de TempoRESUMO
Neurocritical care relies on the continuous, real-time measurement of numerous physiologic parameters. While our capability to obtain such measurements from patients has grown markedly with multimodal monitoring in many neurologic or neurosurgical intensive care units (ICUs), our ability to transform the raw data into actionable information is limited. One reason is that the proprietary nature of medical devices and software often prevents neuro-ICUs from capturing and centrally storing high-density data. Also, ICU alarm systems are often unreliable because the data that are captured are riddled with artifacts. Informatics is the process of acquiring, processing, and interpreting these complex arrays of data. The development of next-generation informatics tools allows for detection of complex physiologic events and brings about the possibility of decision support tools to improve neurocritical care. Although many different approaches to informatics are discussed and considered, here we focus on the Bayesian probabilistic paradigm. It quantifies the uncertainty inherent in neurocritical care instead of ignoring it, and formalizes the natural clinical thought process of updating prior beliefs using incoming patient data. We review this and other opportunities, as well as challenges, for the development and refinement of informatics tools in neurocritical care.
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Unidades de Terapia Intensiva/normas , Informática Médica/normas , Monitorização Fisiológica/normas , Neurologia/normas , Neurocirurgia/normas , Sistemas de Apoio a Decisões Clínicas/instrumentação , Sistemas de Apoio a Decisões Clínicas/normas , Humanos , Informática Médica/instrumentação , Informática Médica/métodos , Monitorização Fisiológica/instrumentação , Monitorização Fisiológica/métodos , Neurologia/instrumentação , Neurocirurgia/instrumentação , Neurocirurgia/métodosRESUMO
BACKGROUND: Tubular spine surgery has emerged as a hallmark of minimally invasive spine (MIS) procedures. In recent years, thanks to technological advances, tubular dilators and retractors have been integrated with digital cameras to allow for ergonomic, high-definition visualization of the surgical field. OBJECTIVE: To detail the evolution, ergonomics, economics, and outcomes of camera-based tubular spine surgery, spanning the origins of MIS tubular techniques to the current use of operative microscopes and tube-mounted digital cameras (TMDCs). METHODS: This is a narrative review of studies examining the evolution of tubular spine surgery as well as its most recent advances, with a particular emphasis on advances in visualization of the surgical field. RESULTS: Despite early resistance to tubular techniques due to a steep learning curve, minimally invasive tubular approaches are being increasingly adopted by the mainstream spine surgical community, which has resulted in an expansion of both indications and procedural modalities. This can largely be attributed to the increased quality of visualization, as evidenced by improvements in microscopes as well as emerging technologies like exoscopes and TMDCs. Tubular MIS procedures have also achieved superior efficacy compared with open surgical approaches for the treatment of several spinal pathologies while allowing for improved ergonomics, which may have lasting consequences on surgeon longevity. CONCLUSIONS: Advances in visualization technologies have allowed tubular surgery to become an effective, ergonomic, and muscle-sparing alternative to open spine surgery. Further research is necessary to quantify the true costs and outcomes associated with nascent TMDC technology. CLINICAL RELEVANCE: This work elucidates developments in visualization for tubular spine surgery.
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Professor Sir John Charnley has been rightfully hailed as a visionary innovator for conceiving, designing, and validating the Operation of the Century-the total hip arthroplasty. His groundbreaking achievement forever changed the orthopedic management of chronically painful and dysfunctional arthritic joints. However, the well-accepted surgical approach of completely removing the diseased joint and replacing it with a durable and anatomically based implant never translated to the treatment of the degenerated spine. Instead, decompression coupled with fusion evolved into the workhorse intervention. In this commentary, the authors explore the reasons why arthrodesis has remained the mainstay over arthroplasty in the field of spine surgery as well as discuss the potential shift in the paradigm when it comes to treating degenerative lumbar disease.
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BACKGROUND AND OBJECTIVES: Percutaneous endoscopic lumbar diskectomy (PELD) is an effective, minimally invasive method for removal of lateral lumbar disk herniations. This minimally invasive technique can be applied with high success and lead to faster recovery than traditional methods. Unfortunately, adoption of these techniques in the United States has been slow. A significant barrier to using this technique is often an inability to completely visualize relevant anatomy and increased operative times. In this article, we describe a technique using computed tomography (CT) guidance in conjunction with a neurogram to perform a PELD. We detail the steps in the technique and its advantages to the surgeon performing it. METHODS: After a patient is placed supine on a table, a transforaminal injection of contrast is performed under fluoroscopic guidance. Then, after sterilizing and draping in a normal fashion, an intraoperative CT scan is taken with a reference frame in place. During the procedure, this allows for the CT guidance to have the exiting nerve root clearly outlined. RESULTS: This procedure was successfully performed in a single patient, allowing greater visualization of the exiting nerve root during a difficult revision PELD case. No complications were experienced. CONCLUSION: A novel technique using a neurogram with CT guidance during a PELD was used to assist with identification of anatomy and decompression of the exiting nerve root. This technique was used without complications.
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Meios de Contraste , Discotomia Percutânea , Deslocamento do Disco Intervertebral , Vértebras Lombares , Raízes Nervosas Espinhais , Tomografia Computadorizada por Raios X , Humanos , Vértebras Lombares/cirurgia , Vértebras Lombares/diagnóstico por imagem , Tomografia Computadorizada por Raios X/métodos , Raízes Nervosas Espinhais/diagnóstico por imagem , Raízes Nervosas Espinhais/cirurgia , Discotomia Percutânea/métodos , Deslocamento do Disco Intervertebral/cirurgia , Deslocamento do Disco Intervertebral/diagnóstico por imagem , Meios de Contraste/administração & dosagem , Masculino , Endoscopia/métodos , Pessoa de Meia-Idade , FemininoRESUMO
Activity trackers and wearables allow accurate determination of physical activity, basic vital parameters, and tracking of complex medical conditions. This review attempts to provide a roadmap for the development of these applications, outlining the basic tools available, how they can be combined, and what currently exists in the marketplace for spine patients. Various types of sensors currently exist to measure distinct aspects of user movement. These include the accelerometer, gyroscope, magnetometer, barometer, global positioning system (GPS), Bluetooth and Wi-Fi, and microphone. Integration of data from these sensors allows detailed tracking of location and vectors of motion, resulting in accurate mobility assessments. These assessments can have great value for a variety of healthcare specialties, but perhaps none more so than spine surgery. Patient-reported outcomes (PROMs) are subject to bias and are difficult to track frequently - a problem that is ripe for disruption with the continued development of mobility technology. Currently, multiple mobile applications exist as an extension of clinical care. These include Manage My Surgery (MMS), SOVINITY-e-Healthcare Services, eHealth System, Beiwe Smartphone Application, QS Access, 6WT, and the TUG app. These applications utilize sensor data to assess patient activity at baseline and postoperatively. The results are evaluated in conjunction with PROMs. However, these applications have not yet exploited the full potential of available sensors. There is a need to develop smartphone applications that can accurately track the functional status and activity of spine patients, allowing a more quantitative assessment of outcomes, in contrast to legacy PROMs.
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OBJECTIVE: Our primary objective was to compare the intraoperative costs of 3 different surgical visualization techniques for anterior cervical discectomy and fusion (ACDF). Specifically, we used time-driven activity-based costing (TDABC) methodology to compare costs between ACDFs performed with operative microscopes (OM-ACDF), exoscopes (EX-ACDF), and loupes (loupes-ACDF). METHODS: Total cost was divided into direct and indirect costs. Individual costs were obtained by direct observation, electronic medical records, and through querying multiple departments (business operations, sterile processing, plant operations, and pharmacy). Timestamps for all involved personnel and material resources were documented. We identified all instances of loupes-ACDF (n = 882), EX-ACDF (n = 26), and OM-ACDF (n = 52) performed at our institution. We performed multivariable linear regression analyses to compare costs between these modalities, accounting for patient-specific factors as well as number of levels fused, surgeon, and hospital site. RESULTS: The average total intraoperative costs per loupes-ACDF, EX-ACDF, and OM-ACDF cases were $7081 +/- $2,942, $7951 +/- $3,488, and $6557 +/- $954, respectively. Regression analysis revealed no difference in intraoperative cost between loupes-ACDF and EX-ACDF (P = 0.717), loupes-ACDF and OM-ACDF (0.954), or OM-ACDF and EX-ACDF (0.217). On a more granular level, however, EX-ACDF was associated with increased cost of consumables, including drapes, compared to both OM-ACDF (ß-coefficient: $369 +/- $121, P = 0.002) and loupes-ACDF (ß-coefficient: $284 +/- $86, P = 0.001). CONCLUSIONS: Although hospitals may be aware of the purchasing fees associated with microscopes and exoscopes, there is no clear documentation of how these technologies affect intraoperative cost. We demonstrate a novel use of TDABC for this purpose.
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Fusão Vertebral , Cirurgiões , Humanos , Fusão Vertebral/métodos , Custos e Análise de Custo , Discotomia/métodos , Vértebras Cervicais/cirurgia , Estudos Retrospectivos , Resultado do TratamentoRESUMO
OBJECTIVE: Spine surgeons are often unaware of drivers of cost variation for anterior cervical discectomy and fusion (ACDF). We used time-driven activity-based costing to assess the relationship between body mass index (BMI), total cost, and operating room (OR) times for ACDFs. METHODS: Total cost was divided into direct and indirect costs. Individual costs were obtained by direct observation, electronic medical records, and through querying multiple departments. Timestamps for all involved personnel and material resources were documented. Total intraoperative costs were estimated for all ACDFs from 2017 to 2022. All patients were categorized into distinct BMI-based cohorts. Linear regression models were performed to assess the relationship between BMI, total cost, and OR times. RESULTS: A total of 959 patients underwent ACDFs between 2017 and 2022. The average age and BMI were 58.1 ± 11.2 years and 30.2 ± 6.4 kg/m2, respectively. The average total intraoperative cost per case was $7120 ± $2963. Multivariable regression analysis revealed that BMI was not significantly associated with total cost (P = 0.36), supply cost (P = 0.39), or personnel cost (P = 0.20). Higher BMI was significantly associated with increased time spent in the OR (P = 0.018); however, it was not a significant factor for the duration of surgery itself (P = 0.755). Rather, higher BMI was significantly associated with nonoperative OR time (P < 0.001). CONCLUSIONS: Time-driven activity-based costing is a feasible and scalable methodology for understanding the true intraoperative costs of ACDF. Although higher BMI was not associated with increased total cost, it was associated with increased preparatory time in the OR.
Assuntos
Índice de Massa Corporal , Vértebras Cervicais , Discotomia , Duração da Cirurgia , Fusão Vertebral , Humanos , Discotomia/economia , Discotomia/métodos , Fusão Vertebral/economia , Fusão Vertebral/métodos , Pessoa de Meia-Idade , Feminino , Masculino , Vértebras Cervicais/cirurgia , Idoso , Custos e Análise de Custo , Salas Cirúrgicas/economia , AdultoRESUMO
BACKGROUND AND OBJECTIVES: Endoscopic lumbar diskectomy (ED) is a minimally invasive option for addressing lumbar disk herniations. With the introduction of value-based care systems, assessing the true cost of certain procedures is critical when creating reimbursement models and comparing procedures. Here, we compared the costs of performing a microdiskectomy (MD) and ED using time-driven activity-based costing. METHODS: Total cost for the intraoperative episode was calculated using time-driven activity-based costing methodology. Individual costs were obtained by direct observation and electronic medical records and through querying multiple departments (business operations, sterile processing, plant operations, and pharmacy). Timestamps for all involved personnel and material resources were documented. A retrospective analysis was performed on 202 patients who underwent lumbar diskectomy through either MD (n = 167) or ED (n = 35) from 2018 to 2022. Personnel cost was calculated by multiplying the cost per unit time for each personnel type by the length of time spent in the operating room. Supply cost was calculated by aggregating the cost of all individual supplies, from medications to consumables to surgical trays, used during the case. Univariate and multivariable regression analyses were performed comparing the costs between these procedures. RESULTS: The average intraoperative cost per case for ED and MD was $3915 ± $1025 and $3162 ± $954, respectively. Multivariable regression analysis revealed that ED had higher total cost (ß-coefficient: $912 ± $281, P = <.01) and supply cost (ß-coefficient: $474 ± $155, P = <.01) than MD. When accounting for surgeon as a covariate, however, total cost (P = .478) and supply cost (P = .468) differences between ED and MD were negligible. CONCLUSION: ED has shown to be a better value option in addressing lumbar disk herniations, mostly because of advantages in perioperative care. Here, we show that when correcting for surgeon-level effects, the cost between the two procedures is statistically insignificant, reaffirming the value provided by ED.
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BACKGROUND AND OBJECTIVE: Our primary objective was to compare the marginal intraoperative cost of 3 different methods for pedicle screw placement as part of transforaminal lumbar interbody fusions (TLIFs). Specifically, we used time-driven activity-based costing to compare costs between robot-assisted TLIF (RA-TLIF), TLIF with intraoperative navigation (ION-TLIF), and freehand (non-navigated, nonrobotic) TLIF. METHODS: Total cost was divided into direct and indirect costs. We identified all instances of RA-TLIF (n = 20), ION-TLIF (n = 59), and freehand TLIF (n = 233) from 2020 to 2022 at our institution. Software was developed to automate the extraction of all intraoperatively used personnel and material resources from the electronic medical record. Total costs were determined through a combination of direct observation, electronic medical record extraction, and interdepartmental collaboration (business operations, sterile processing, pharmacy, and plant operation departments). Multivariable linear regression analysis was performed to compare costs between TLIF modalities, accounting for patient-specific factors as well as number of levels fused, surgeon, and hospital site. RESULTS: The average total intraoperative cost per case for the RA-TLIF, ION-TLIF, and freehand TLIF cohorts was $24 838 ± $10 748, $15 991 ± $6254, and $14 498 ± $6580, respectively. Regression analysis revealed that RA-TLIF had significantly higher intraoperative cost compared with both ION-TLIF (ß-coefficient: $7383 ± $1575, P < .001) and freehand TLIF (ß-coefficient: $8182 ± $1523, P < .001). These cost differences were primarily driven by supply cost. However, there were no significant differences in intraoperative cost between ION-TLIF and freehand TLIF ( P = .32). CONCLUSION: We demonstrate a novel use of time-driven activity-based costing methodology to compare different modalities for executing the same type of lumbar fusion procedure. RA-TLIF entails significantly higher supply cost when compared with other modalities, which explains its association with higher total intraoperative cost. The use of ION, however, does not add extra expense compared with freehand TLIF when accounting for confounders. This might have implications as surgeons and hospitals move toward bundled payments.
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Custos e Análise de Custo , Vértebras Lombares , Procedimentos Cirúrgicos Robóticos , Fusão Vertebral , Humanos , Fusão Vertebral/economia , Fusão Vertebral/métodos , Fusão Vertebral/instrumentação , Vértebras Lombares/cirurgia , Procedimentos Cirúrgicos Robóticos/economia , Procedimentos Cirúrgicos Robóticos/métodos , Masculino , Feminino , Pessoa de Meia-Idade , Custos e Análise de Custo/métodos , Idoso , Parafusos Pediculares/economia , AdultoRESUMO
BACKGROUND: Elective lumbar fusions have received criticism for inappropriate utilization. Here, we use a novel Operative Value Index (OVI) to assess whether "indicated," evidence-based lumbar fusions are associated with increased value (outcomes per dollar spent). METHODS: This study is a retrospective analysis of a prospective observational cohort of 294 patients undergoing elective lumbar fusions at a single large academic institution. All patients were preoperatively evaluated by a panel of neurosurgeons for concordance with evidence-based medicine (EBM), determined through guidelines from the North American Spine Society. Oswestry Disability Index (ODI) scores were collected for all patients both preoperatively and at 6-months postoperatively. Time-driven activity-based costing was employed to determine both direct and indirect intraoperative costs. The OVI was defined as the percent improvement in ODI per $1000 spent intraoperatively. Generalized linear mixed model regression, adjusting for confounders, was performed to assess whether EBM-concordant surgeries were associated with higher OVI. RESULTS: Of 294 elective lumbar fusions, 92.9% (n = 273) were EBM-concordant. The average total cost of an EBM-concordant lumbar fusion was $17,932 (supplies: $13,020; personnel: $4314), compared to $20,616 (supplies: $15,467; personnel: $4758) for an EBM-discordant fusion. Average OVI was 2.27 for a concordant fusion, compared to 0.11 for a discordant fusion. Generalized linear mixed model analysis revealed that EBM-concordant cases were associated with significantly higher OVI (ß-coefficient 2.0, P < 0.001). CONCLUSIONS: EBM-concordant fusions were associated with 2% greater improvement in ODI scores from baseline for every $1000 spent intraoperatively. Systematic methods for increasing guideline adherence for lumbar fusions could therefore improve value at scale.